Provider Demographics
NPI:1114325776
Name:ANTHONY J. SIDOR, D.D.S., P.A.
Entity Type:Organization
Organization Name:ANTHONY J. SIDOR, D.D.S., P.A.
Other - Org Name:MERRITT ISLAND SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SIDOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-453-1890
Mailing Address - Street 1:225 S PLUMOSA ST
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3525
Mailing Address - Country:US
Mailing Address - Phone:321-453-1890
Mailing Address - Fax:
Practice Address - Street 1:225 S PLUMOSA ST
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3525
Practice Address - Country:US
Practice Address - Phone:321-453-1890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN13170122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty